Abstract
Point-of-care ultrasound (POCUS) has emerged as a powerful tool for bedside diagnosis and management, offering real-time clinical insights and cost savings. Its integration into rural family medicine could reduce reliance on advanced imaging, improve patient satisfaction, and support physician versatility across primary, emergency, and procedural care. Despite these advantages, POCUS adoption remains limited, largely due to ambiguous and inconsistent reimbursement policies. Rural Health Clinic all-inclusive payment models, state Medicaid variability, and Local Coverage Determination gaps undermine financial sustainability. Cost analyses demonstrate meaningful system-level savings, yet physician revenue remains constrained, particularly in Medicare-heavy rural populations. Policy solutions include adjusting rural payment models, establishing national Local Coverage Determinations (LCDs), introducing visit modifiers, and leveraging tele-ultrasound and hybrid training approaches. Complementary pathways, such as limited out-of-pocket patient payments, may provide short-term support but risk inequities. Aligning reimbursement policy with demonstrated clinical and economic benefits is critical to scaling POCUS in rural family medicine and strengthening equitable access to care.
- Family Medicine
- Health Insurance Reimbursement
- Health Services Accessibility
- Insurance Carriers
- Medicare
- Physicians
- POCUS
- Point-of-Care Systems
- Rural Population
- Technology
- Third-Party Payers
- Ultrasonography
Introduction
Point-of-care ultrasound (POCUS) has become an integral part of clinical care and medical diagnostics, enabling real-time, in-depth assessments at the patient's bedside.1 The cost-effectiveness and power of POCUS have been validated over the past decade, particularly in emergency medicine.2 A 2023 JEM article used a Monte Carlo simulation model to estimate the national economic impact of adopting a POCUS-first approach for evaluating suspected kidney stones in emergency departments.3 By using POCUS to rule in kidney stone diagnosis for patients meeting Choosing Wisely criteria, reducing the need for confirmatory Computed Tomography (CT) scans, the model projected $16.5 million in annual cost savings, a significant reduction in emergency department length of stay, and the prevention of excess radiation-related cancers. These findings highlight the enormous potential for POCUS to deliver not only safer but also more cost-effective care. Introducing POCUS into rural family practices could similarly lower health care costs by ruling in specific diagnoses such as gallbladder disease or kidney stones, thereby reducing the need for advanced imaging when these conditions are identified.2 For rural family medicine practices, where physicians face limited access to resources, specialists, and advanced imaging technologies, POCUS provides an effective and reliable alternative. However, despite its clinical advantages, POCUS reimbursement remains a significant challenge, with a complex and inconsistent process for coverage or reimbursement across Medicare, Medicaid, and private insurance, further complicated by regional variations.4 However, recent innovations including remote expert interpretation services and hybrid virtual training models are beginning to create new implementation pathways for rural physicians.1 Here, we explore the current POCUS reimbursement landscape, its challenges, and opportunities for improvement.
The Role of POCUS in Rural Family Medicine
In rural areas, family physicians and other clinicians wear multiple health care hats, serving as primary care physicians, emergency physicians, and specialists. Thus, POCUS, the use of a portable ultrasound device for bedside diagnostic imaging, can be invaluable in these settings. Studies demonstrate that POCUS can be effectively utilized across various applications, from identifying abdominal pathologies to guiding procedures like line placement and abscess drainage, and supporting obstetric care.4 This broad scope of practice, in rural settings, combined with limited access to advanced imaging and specialists, makes POCUS a critical resource. Studies show that POCUS improves patient care by enabling quicker diagnosis, satisfaction, reducing unnecessary referrals, and allowing physicians to perform detailed procedures like ultrasound-guided injections or central venous access. The realization of these benefits, however, requires adequate training infrastructure and image storage capabilities that enable specialist consultation, which may not be available in all rural practice settings. Additional limitations include operator variability in image acquisition and interpretation, potential for misdiagnosis when used beyond practitioner competency levels, and ongoing costs for equipment maintenance, software updates, and continuing education requirements that can strain rural practice budgets.
Yet, despite its proven advantages, less than 10% of primary care physicians reported using POCUS regularly in a 2021 survey.5 In the Veterans Affairs (VA) system, adoption is similarly limited, only 13% of primary care clinics use POCUS, and a lack of trained providers, approximately 78%, along with equipment and training funding, is a predominant barrier, highlighting wide variability and resource gaps across practice settings.6 This low adoption rate stems from factors including initial investment and maintenance costs, training requirements, reimbursement, and liability issues. Of these, reimbursement remains the most ambiguous and challenging factor to navigate. New residency curriculum guidelines from American Academy of Family Physicians aim to accelerate the adoption of POCUS in rural family settings, but it will take years of training new physicians before it becomes mainstream.
Economic and Patient-Centered Impacts of POCUS in Rural Family Medicine
For rural family physicians to fully integrate POCUS into their practices, appropriate reimbursement is essential, as without it, clinicians are less likely to invest in the substantial upfront costs of equipment and staff training.
Financial Impact: Cost-Saving Potential and Barriers
POCUS has shown significant cost-saving potential by reducing unnecessary imaging and improving clinical decision making. For example, a 2019 case study in a Boston community hospital conducted a cost-saving analysis of leveraging POCUS.7 Over a 3-month period, emergency physicians were interviewed during shifts whenever POCUS was used to assess its impact on clinical management and avoided testing, with cost estimates based on CMS and FairHealth data. On average, POCUS eliminated $1,134.31 in additional testing costs for privately insured patients, $2,826.31 for uninsured or out-of-network patients, and $181.63 for CMS patients, with differences significant compared with no savings (P < .001). These findings reveal a significant limitation for rural POCUS adoption: cost savings are substantially lower for Medicare patients ($181.63) compared with privately insured patients ($1,134.31). Given that rural populations have higher Medicare enrollment rates, with some rural counties exceeding 25% Medicare beneficiaries compared with 16% nationally, the economic case for POCUS in rural settings is considerably weaker than these aggregate figures suggest. Device cost assumptions for this analysis encompassed the price range from handheld units (approximately $8,000–$10,000) to midlevel cart-based systems (ranging from $10,000 to $120,000+), explicitly excluding ultraportable models. However, the clinical utility and cost-effectiveness of different POCUS device categories varies significantly in rural settings, where advanced portable systems may provide greater diagnostic confidence, but handheld devices offer easier adoption and lower financial risk. This framing helps ground the cost-savings implications in realistic equipment investment terms. Aggregate cost savings remained significant even when including encounters where POCUS did not change clinical management.7 These cost savings occurred primarily when POCUS successfully ruled in specific diagnoses such as gallbladder pathology or confirmed the presence of kidney stones, thereby eliminating the need for confirmatory advanced imaging rather than replacing comprehensive diagnostic workups. Similarly, in a prospective Canadian emergency department study, patients assessed with POCUS had a median investigation cost of $102.00 compared with $122.40 in the control group (P = .08). Among patients discharged from the hospital, POCUS use significantly lowered median costs to $71.80 versus $122.70 (P < .001), with additional savings seen in flank pain cases ($138.90; P = .01). These represent savings to the health system and patients rather than increased physician revenue. Beyond cost savings, successful large-scale implementation is also being demonstrated. British Columbia's Rural POCUS Strategy successfully equipped over 50 rural physicians through virtual training programs, showing that scalable rural implementation is achievable.8 These findings show that POCUS can meaningfully reduce diagnostic costs without compromising patient care. There were no differences between groups in the number of investigations ordered, 7-day Emergency Department (ED) revisit rates, or safety outcomes.9 For rural practices, while patient transfers to tertiary facilities are costly and logistically challenging, the predominance of Medicare patients in rural areas suggests that actual cost savings may be substantially lower than these mixed-payer studies indicate, further emphasizing the importance of adequate reimbursement mechanisms rather than relying primarily on cost-offset justifications. This disconnect between societal cost savings and physician revenue loss underscores why appropriate POCUS reimbursement is essential for sustainable rural adoption.
Despite POCUS's benefits, rural family medicine adoption is limited by high upfront costs and variable reimbursement policies. POCUS encompasses a spectrum of devices with varying capabilities and costs. Ultraportable handheld devices (eg, Butterfly IQ, GE Vscan) cost $2,000–$8,000 and offer basic imaging suitable for simple diagnostic questions. Midrange portable systems (eg, GE Venue Go) cost $15,000–$50,000 and provide imaging quality approaching traditional cart-based systems. Training costs range from $1,000–$3,000 for handheld devices to $3,000–$5,000 for advanced portable systems. For rural settings, the choice between device categories significantly impacts both cost-effectiveness and clinical utility, with handheld devices offering lower barriers to adoption but potentially limiting diagnostic capabilities. Current reimbursement structures, especially in Rural Health Clinics (RHCs) where payments are often bundled into broader codes or all-inclusive rates, make these costs difficult to recover.
Patient-Centered Impacts: Quality Metrics and Satisfaction
Despite its economic benefits, POCUS also enhances patient satisfaction and perceived care quality.10 Research shows a “positive care effect,” with improved satisfaction and care efficiency. Patients report greater trust and confidence during POCUS encounters, with heightened engagement during real-time image interpretation.10 One study found median patient satisfaction scores of 5.0 out of 5, with 59% giving the highest possible rating.10
In rural family medicine, where strong physician-patient relationships are crucial, POCUS's ability to strengthen therapeutic alliances is particularly valuable. By providing real-time reassurance and addressing concerns at bedside, rural physicians can build trust, reduce anxiety, and improve treatment adherence. These socioemotional benefits, combined with clinical and financial advantages, make POCUS critical for rural health care improvement. Targeted policy reforms could unlock POCUS's full potential in rural family medicine.
Reimbursement Challenges for POCUS in Rural Family Medicine
Although Current Procedural Terminology (CPT) codes for ultrasound imaging and procedural guidance exist, reimbursement in rural health practices is constrained by Medicare’s all-inclusive rate (AIR) system. Under this model, Rural Health Clinics (RHCs) receive a single per-visit payment that bundles all services provided during the encounter, including POCUS.11 This structure creates barriers for rural Physicians: the bundling of payments discourages investment in POCUS, variability in state Medicaid and private insurer policies creates reimbursement uncertainty, and documentation requirements (eg, image archiving, detailed reporting) can overburden small practices. Thus, while technical billing codes for POCUS exist, current payment system architecture—especially bundled AIR models—prevent rural Physicians from realizing direct reimbursement for their use, limiting the financial viability of POCUS despite its demonstrated clinical benefits.
How the RHC AIR Works in 2025
RHCs are paid a single all-inclusive rate per visit for medically necessary primary and preventive services furnished by an RHC practitioner; Medicare pays 80% of the AIR and patients/secondaries pay 20% coinsurance. For CY 2025, the national statutory per-visit payment limit is $152.00 (with special rules for certain “specified” Physician-based RHCs). Practically, the professional work of bedside POCUS performed by the RHC practitioner is bundled into the encounter payment, not paid separately.11
What Can Be Billed Outside the AIR: The Technical Component (TC) of Diagnostic Tests
Medicare policy distinguishes between professional services (generally bundled into the AIR) and the technical component of diagnostic tests (eg, imaging). The TC may be billed separately outside the AIR under Part B - typically by the parent hospital for Physician-based RHCs (on a UB-04/837I) or by the independent RHC/supplier (on a 1500/837P), while the professional component remains part of the RHC visit. Ultrasound services fall under this diagnostic-test framework. This arrangement creates operational complexity for small rural practices and limits any incremental professional reimbursement for POCUS.12,13
Critical Access Hospitals (CAHs) versus RHCs: Why the Setting Matters for POCUS
When POCUS is provided in a Critical Access Hospital (CAH) outpatient department, the facility side is paid at 101% of reasonable costs. If the CAH elects Method II, it may also bill the professional services at 115% of the Medicare Physician Fee Schedule (PFS) (when clinicians reassign billing). Many rural family physicians practice within systems that include RHCs attached to CAHs; in those cases, facility (TC) dollars flow through the CAH, but the RHC visit (PC/practitioner work) remains under AIR - a split that can dilute the financial return to the clinic team actually performing POCUS.11
Medicaid and Commercial Payers: Heterogeneity Adds Uncertainty
Medicaid payment to RHCs varies by state (eg, PPS vs APM models), and state manuals typically mirror Medicare’s split: diagnostic test TC may be billed separately, while the professional portion rolls into the encounter. This variability across states and commercial plans creates planning uncertainty for rural practices adopting POCUS.14
Local Coverage Determinations and Medicare Administrative Contractor Complicates Coverage
Reimbursement for POCUS under Medicare is further complicated by Local Coverage Determinations (LCDs), which vary by region and Medicare Administrative Contractor (MAC). LCD determines whether Medicare covers a service within a specific jurisdiction.15 Some ultrasound services are not governed by an LCD in some MAC regions. When there’s no LCD, coverage falls back to the National Coverage Determination (NCD) for Ultrasound Diagnostic Procedures and the general “reasonable and necessary” standard. Below are 2 CPT examples of unclear LCD coverage under the current guidelines:
Extremity Ultrasound (CPT 76881/76882)
Covered under LCD L33619 in NGS Jurisdiction J6 (Illinois, Minnesota, Wisconsin). This LCD outlines specific limitations that include for instance, routine evaluation of cellulitis or abscess, may not meet medical necessity.16
Chest/Lung Ultrasound (CPT 76604)
No dedicated LCD in several MAC regions, such as Noridian JE/JF and Novitas JL/JH. In the Medicare Coverage Database, chest ultrasound is not listed among active LCDs, so coverage defaults to the National Coverage Determination (NCD) and local medical necessity policies.12,16
Together, these features mean that POCUS revenue is often limited under the RHC AIR, especially where practices cannot submit a separate technical component claim via a hospital/CAH or other facility enrollment. Even when a facility pathway exists, operational requirements (image storage, report documentation, routing TC/PC claims correctly) can exceed the administrative capacity of small rural practices - further depressing net reimbursement for POCUS relative to its clinical value.12
The core barrier is not the absence of CPT codes, but rather AIR bundling and caps at RHCs, the difficulty many rural practices face in accessing a separate TC billing pathway, and state/plan-level variation in encounter payment methods. Addressing these would better align payment with the clinical benefits of POCUS in rural primary care.
Direct Out-of-Pocket Payments as Financing Model
While our analysis emphasizes reimbursement via third-party payers, a complementary and pragmatic financing pathway in rural family medicine is direct patient payment. Evidence from a Hungarian primary care setting showed that patients were willing to pay approximately 5000 HUF (∼US $13–$14) for a POCUS examination, and that 99.4% were willing to do so when the GP was formally trained compared with only 45.9% if not certified.17 This suggests that rural practices may implement nominal out-of-pocket fees, for example, $15–$25 for a POCUS-guided procedure that patients perceive as worthwhile if it avoids referral-related delays, travel, or higher costs. However, reliance on self-pay raises equity concerns, as ability and willingness to pay vary across socioeconomic groups. Therefore, while direct reimbursement from patients can help sustain POCUS adoption in the short term, it must operate alongside efforts to expand third-party coverage and institutional support to ensure equitable access.
Potential Solutions to Improve POCUS Reimbursement in Rural Family Medicine
Policy makers have strong potential to strengthen adoption by adjusting rural payment models. Allowing POCUS to be reimbursed outside the RHC all-inclusive rate, or leveraging existing rural hospital designations such as Critical Access Hospitals (CAHs), which already receive enhanced reimbursement (101% of reasonable costs for facility services and up to 115% of the Medicare Physician Fee Schedule for professional services under Method II). Standardizing LCD coverage across regions requires coordinated advocacy through professional societies such as the American Academy of Family Physicians, who could submit unified coverage requests to Medicare Administrative Contractors with evidence-based clinical guidelines. CMS could also establish a national LCD for commonly used rural POCUS procedures that currently lack consistent coverage.
Visit modifiers also represent a promising mechanism for rural POCUS reimbursement within existing billing structures. Standard E&M codes (99202 to 99215) could be augmented with POCUS-specific modifiers: -PU for basic applications (bladder scan, FAST examination) adding 15 to 20% to the base reimbursement, and -PC for complex procedures (procedural guidance, multi-organ assessment) adding 25 to 35%. This would work within RHC constraints by modifying the all-inclusive rate calculation rather than billing separate procedures. CMS could establish a tiered AIR system where POCUS-enhanced visits receive higher reimbursement rates ($165 for basic, $180 for intermediate, $200 for complex compared with the current $152 base rate).
For tele-ultrasound integration, regulatory frameworks could leverage existing telehealth billing structures under CPT codes with GT modifiers, allowing remote interpretation services to be billed separately. Pilot programs within existing CMS Innovation Center rural health models could test bundled payments that specifically include POCUS services, providing real-world data to support broader policy adoption.18,19
Complementing these policy approaches, emerging implementation strategies show additional promise. Remote expert interpretation services allow rural Physicians to transmit POCUS images for specialist review, creating reimbursement opportunities outside traditional RHC bundling constraints. In addition, hybrid training curricula combining virtual and in-person education have proven effective in resource-limited settings, significantly reducing traditional barriers of cost and mentorship availability.20,21
Another pathway for advancing reimbursement is through the CPT Editorial Panel process, which determines the development and modification of CPT codes. Specialty societies and individual clinicians play a central role in initiating and supporting these changes by submitting proposals, supplying utilization data, and demonstrating clinical value (American Medical Association CPT Code Process). While CMS ultimately governs coverage and payment, the AMA CPT pathway underscores that progress depends not only on federal advocacy but also on grassroots action from clinicians and professional organizations. Engaging family medicine societies, emergency medicine societies, and cross-disciplinary groups to jointly petition for updated descriptors or new codes could help POCUS services become more formally recognized within reimbursement structures. In parallel, continued research is critical for strengthening these policy efforts. Much of the existing cost-savings and clinical utility evidence derives from emergency department studies,7,9 but payers and policy makers often require patient-oriented, primary-care–specific data to justify expanded coverage. Key research gaps include patient satisfaction and trust during POCUS encounters.10 Physician satisfaction and workflow impacts in rural settings. Comparative outcomes when training occurs during medical school or residency versus later in practice. Rural-specific implementation studies, rather than extrapolation from tertiary or ED cohorts.4 By pairing rigorous, patient-centered research with organized advocacy through specialty societies, rural clinicians can both strengthen the evidence base and accelerate policy traction, ensuring that reimbursement policies reflect the true clinical and economic value of POCUS.
While these solutions highlight promising pathways, it is important to acknowledge that implementation is complex and requires the coordination of many moving parts. Efforts such as establishing national LCDs, integrating tele-ultrasound billing, or advancing new CPT proposals demand not only regulatory change but also collaboration among insurers, hospital systems, specialty societies, and rural practices themselves. In practice, these initiatives face challenges related to variable image quality standards, documentation and archiving requirements, payer acceptance, and the significant time burden on small practices. As a result, although these reforms remain achievable, they represent longer-term strategies that will require sustained advocacy, pilot testing, and infrastructure support to become viable at scale. Including this perspective helps frame policy innovation not as an immediate fix, but as part of a broader, staged roadmap toward sustainable reimbursement.
These challenges are amplified by broader structural pressures: recent federal legislation introduced $911 billion in Medicaid cuts over 10 years, disproportionately affecting rural hospitals and clinics.22 To offset these losses, Congress authorized the $50 billion Rural Health Transformation Program (RHT Program), which will provide states with annual grants beginning in FY 2026 to support initiatives such as chronic disease management, workforce recruitment, and technology adoption.23,24 While POCUS could theoretically be funded under the program’s “technology adoption” provisions, states must prioritize multiple competing needs, and the limited pool of funding is unlikely to cover the training, equipment, and reimbursement structures necessary for widespread implementation in family practice. Because funding is distributed at the state level and covers only an estimated one-third of projected rural losses, the program is unlikely to fully stabilize rural practices or ensure sustainable POCUS integration.25,26 Rural physicians thus remain caught between the promise of new technology and the reality of structural underinvestment, making federal and state policy alignment critical to prevent POCUS from becoming another underutilized tool in underserved communities.
Conclusion
POCUS offers significant potential for advancing rural family medicine through cost-effective clinical diagnosis and patient management, particularly in addressing resource and access constraints in remote areas. However, ambiguous reimbursement policies create substantial barriers to widespread rural adoption. Key steps forward include clarifying reimbursement policies and expanding telemedicine integration, while advocating for national and state policy changes. Improving POCUS reimbursement through both traditional policy reform and emerging remote interpretation and hybrid training models will enhance Physician sustainability and patient access to quality care, where timely diagnosis and treatment remain critical.
Notes
This article was externally peer reviewed.
Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.
Conflict of interest: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
- Received for publication December 31, 2024.
- Revision received August 30, 2025.
- Accepted for publication September 22, 2025.
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